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HIV Disparities in the South

Richard Wolitski, Ph.D., Director,
Office of HIV/AIDS and Infectious Disease Policy
U.S. Department of Health and Human Services-

Why did it take us so long to focus our attention on the disparities experienced in the South? Was it that AIDS was first identified in big cities on the east and west coasts—Los Angeles, San Francisco, and New York? Is it that we’ve become desensitized to reports showing that people living in the South are worse off than others on a wide range of health measures? Is it about maintaining the status quo when it comes to funding? Or do unconscious biases about the South and the people who live there play a role?

I lived in Georgia for 20 years, but I’m not able to answer these questions. I do know however, that we need to pay more attention to HIV in the South and the ways that race/ethnicity come into play in addressing issues of prevention, testing, and treatment.

The numbers are disturbing. The South accounts for more cases of HIV than it should; southern states are home to only 37% of the U.S. population, but account for 44% of new HIV diagnoses and 52% of all AIDS diagnoses. People living with HIV in the South are less likely to: be diagnosed; be linked to HIV care and remain in care; and to attain the levels of viral suppression that are needed to keep the virus from destroying the immune system. These effects add up—in some states, Southerners diagnosed with HIV are 3 times as likely to die as those living with HIV in other states.

These and other facts are very much on the minds of many of us who work on HIV issues. In April, CDC’s domestic HIV/AIDS prevention program hosted a town hall meeting to discuss the subject of HIV in the South. The meeting brought together federal colleagues from multiple Departments and agencies, university researchers, community service providers, and many other stakeholders, which gave those of us attending a chance to hear from a wide range of individuals and organizations.

The discussion was open, honest, and came from the hearts of those who have dedicated themselves to improving the lives of people at risk for, or living with, HIV. We talked about the major challenges to delivering HIV prevention and care services in the South. Living in rural areas presented special challenges, as did the reluctance of some leaders to take action. One participant spoke about her frustration with a federally funded health center in her community that had not yet implemented routine HIV screening—even though she lived in a state with one of the highest rates of undiagnosed HIV infection in the country. The participants also talked about some of the particular difficulties facing key populations, including: gay and bisexual men, especially young black and Hispanic/Latino gay/bisexual men; black women; and transgender persons in the South.

We also recognized the harsh reality that the disproportionate rates of HIV infection among racial/ethnic minority populations, particularly among blacks/African Americans, are tightly bound up in the health disparities experienced by people in the South. We acknowledged that too many people still experience stigma and discrimination that prevent them from getting tested, accessing HIV medical care and treatment, and achieving durable viral suppression.

But I don’t wish to leave the impression that all the conversations were negative. Attendees expressed appreciation for the support of the Secretary’s Minority AIDS Initiative Fund (SMAIF), which has allowed them to be innovative and to find new ways of working across program and agency boundaries in the region. They talked about the impact that the SMAIF-funded CAPUS (Care and Prevention in the United States) project had on their communities and how it allowed them to build capacity to respond to the needs of people with HIV in their communities. Doing this has been especially important in rural areas where people have less access to HIV testing, prevention, care, and treatment.

Participants also shared a wealth of innovative solutions, effective strategies, lessons learned, and best practices to address challenges with delivering HIV prevention services to the communities they serve . I’m certain much of what will be needed to turn things around in the South can already be found there—or it can be built by those who know their local HIV profile best.

The discussion illustrated how the challenges of the past, and the realities of the present, give power to stigma and discrimination that affect many different aspects of Southerners’ lives. Internalized and external stigma can make it more difficult for people to see a doctor when they need one, get tested for HIV, get HIV care and treatment, and achieve viral suppression. As a result, progress in reducing HIV infections has been slower in the South than in other parts of the country—but people with HIV die there faster. That’s not fair to the citizens of those states who are living with HIV, at risk for infection, their families, friends, or communities. They all deserve better.

Counteracting those outcomes must be a high priority if we hope to lessen the impact of HIV and AIDS in the South and end the HIV epidemic. As I’ve noted in other blog posts, building relationships and partnerships will be key to achieving that priority. The good news—as the town hall meeting demonstrated—is that we have a highly capable and dedicated group of public health professionals, community leaders, service providers, and researchers who are willing to do just that. By sharing their struggles and their hard-earned wisdom, they are building the bridge to better health—not only for Southerners who are living with HIV, but for all residents of the region.